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AHIMA CDIP Exam Syllabus Topics:

AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. Which of the following is considered a hospital-acquired condition if not present on admission?

A) Blood incompatibility
B) Stage I and II pressure ulcers
C) Diabetes with hypoglycemia
D) Air leak

2. The clinical documentation integrity (CDI) manager reviewed all payer refined-diagnosis related groups (APR-DRG) benchmarking data and has identified potential opportunities for improvement. The manager hopes to develop a work plan to target severity of illness (SOI)/risk of mortality (ROM) by service line and providers. How can the manager gain more information about this situation?

A) Audit focused APR-DRGs and develop education plan for CDI team and physicians
B) Audit cases that have high SOI/ROM assigned by coders for education and follow-up
C) Audit focused cases by physicians that have a higher SOI/ROM for education plan
D) Audit cases for missed diagnosis by the CDI practitioner to target in the education plan

3. A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs:
BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient
has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD, ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

A) Query the physician to clarify if CXR result means patient has pneumonia.
B) Query the physician to clarify for type of COPD such as severe asthma.
C) Query the physician to clarify if patient has acute COPD exacerbation.
D) Query the physician to clarify for clinical significance of the CXR results.

4. A physician documented the specific site of the malignancy in the medical record documentation; however, the coder is unable to locate a specific entry in the ICD-10- CM Alphabetical Index to match the specified diagnosis. Which abbreviation used in the Alphabetical Index will assist the coder in assigning the appropriate diagnosis code for the specified condition?

A) NOS
B) NEC
C) OCE
D) DRG

5. A patient is admitted for chronic obstructive pulmonary disease (COPD) exacerbation. The patient is on 3L of home oxygen and is treated during admission with 3L of oxygen. The most appropriate action is to

A) code the diagnoses of COPD exacerbation and chronic respiratory failure
B) query the provider to see if respiratory insufficiency is supported by the health record
C) query the provider to see if chronic respiratory failure is supported by the health record
D) query the provider to see if acute on chronic respiratory failure is supported by the health record

Solutions: